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Class and Health

When compared to other developed countries, the U.S. ranks near the bottom on most standard measures of health. Many people assume that this is because the U.S. is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. But while it is true that within the U.S. there are enormous disparities by race and ethnic group, even when comparisons are limited to white Americans our performance is “dismal” observes Dr. Steven Schroeder in a lecture published in the New England Journal of Medicine yesterday.

Why? It’s not the lack of universal access to healthcare" says Schroeder, though that’s important. And it’s not just that we don’t exercise enough and eat too much—though that is a major cause. But there is one factor undermining the nation’s health that we just don’t like to talk about in polite society: Class. When it comes to health, class matters.

Schroeder, who is the Distinguished Professor of Health and Health Care at the University of California San Francisco (UCSF) underlines how poorly even white Americans stack up when compared to the citizens of other countries by pointing to maternal mortality as one measure of health. When you look at “all races” you find that in the U.S. 9.9 out of 100,000 women die during childbirth. Focus solely on white women, and the number is still high—7.2 deaths out of 100,000 –especially when compared to Switzerland where only 1.4 women out of 100,000 die while giving birth.

Statistics on infant mortality reveal the same pattern: among “all races” 6.8 American children who were born alive die during infancy; limit the analysis to “whites only” and 5.7 infants die—compared to just 2.7 out of 1,000 in Iceland. .) When researchers compare maternal mortality and infant mortality in white America to rates of death in the 29 other OECD countries, white America ranks close to the bottom third in both categories.

Turn to life expectancy, and you find that white women in the U.S. can expect to live 80.5 years, only slightly longer than American women of all races (who average 80.1 years). Both groups lag far behind Japanese women (who, on average, clock 85.3 years). The gap between “all American men” (who live an average of 74.8 years) and white men in the U.S. (75.3 years) is wider—but not as wide as the gap between white men in the U.S. and men in Iceland (who live an average of 79.7 years).

“How can this be?” asks Schroeder. After all, as everyone knows, the U.S. spends far more on health care than any other nation in the world.

The answer is a stunner: the path “to better health does not generally depend on better health care,” says Schroeder. “Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care.When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of premature deaths could be prevented.” [my emphasis]

Schroeder goes
on to emphasize the importance of behavior, and talks about smoking and obesity—problems that we have discussed on this blog. Then he turns to the causes of
poor health that we tend to ignore: “thenonbehavioral determinants
of health.

Here Schroeder
points to an overwhelming amount of
research (see here,here,
and here)
which confirms that people living on the
lower rungs of the socioeconomic ladder die earlier and suffer from more
disabilities than those who are wealthier, better educated, have a better job
and live in a better residential neighborhood (the four components that
researchers use to define “class”) Moreover,
he notes, “the pattern
holds truein a stepwise fashion from the bottom of the ladder to the top.”

But isn’t the
difference really a function of individual behavior? After all, everyone knows
that poorer, less well-educated people are more likely to smoke and eat junk
food. Schroeder acknowledges that this is true: “people inlower
classes are more likely to have unhealthy behaviors, inpart because
of inadequate local food choices and recreationalopportunities.” In
poorer neighborhoods, fresh and organic foods are usually unavailable or
exorbitantly expensive; public recreation is often nonexistent, and exercising
outdoors can be dangerous.

“Yet, Schroeder points
out, even when behavior is held constant, people in lower classes are less healthy and die earlier than others. [my emphasis]. For example, a
1996 study published in the American
Journal of Public Health which focuses on white American men–and
takes smokingand other risk factors into account– reveals that men earningless than $10,000 were
1.5 times as likely to die prematurely as werethose earning $34,000
or more.

In the U.K.,
a similar study of British civilservants showed that when smoking
and other risk factors werecontrolled for, those in the lowest
employment category werestill more than twice as likely to die
prematurely of cardiovasculardisease as were those in the highest
category.

Why? Schroeder points to a combination of “material
deprivation” and “psychosocial stress.” Being poor generates terrible anxiety, not
just about money, but about safety, your family’s safety, and the fact that
catastrophe—in the form of losing your job and losing your home—is always just around the
corner.

Within
the world of medicine, while some attention has been given to racial disparities
in health and health care, the
importance of class, and “the widedifferences
in health between the haves and the have-nots arelargely ignored,”
Schroeder observes in a 2004 NEJM
article that he co-authored with Stephen L. Isaacs J.D. Clearly, he stresses addressing racism should be a priority: “to bring abouta fair and just
society, every effort should be made to eliminateprejudice and
discrimination.” And often, he admits, it is hard to “disentangle” race and
poverty. But he argues “concentrating mainlyon race as a way of
eliminating these problems of premature death, illness and disability among the
poor downplays
theimportance of socioeconomic status on health.”

“The focus on reducing racial
inequality is understandable sincethis disparity, the result of a
long history of racism and discrimination,is patently unfair,”
Schroeder continues. “Because of the nation’s history and heritage,Americans
are acutely conscious of race. In contrast, classdisparities draw little attention, perhaps because they areseen
as an inevitable consequence of market forces or the factthat life
is unfair. As
a nation, we are uncomfortable withthe concept of class. Americans
like to believe that they livein a society with such potential for
upward mobility that everycitizen’s socioeconomic status is fluid.
The concept of classsmacks of Marxism and economic warfare.” [my
emphasis]

Here let me add, as an aside, that
I have asked a physician who is an expert on racial discrimination and health
care to send me a post for this blog. I hope to publish her comment soon.

But today, I’m focusing on the
socio-economic factors which influence the health of Americans of all races
because in some areas class trumps race. For example, while African-Americans
have higher rates of death from heart attackthan do whites at all
levels of income–and the poorest Americans,whatever their race,
have substantially higher rates of heartattack than those who are
better off –the difference in the rates of premature death from heart attackbetween poorer and richer
people is far greater than the differencein the rates of
premature death between blacks and whites.

But how does class explain why the U.S.lags so far behind other developed countries when we look at markers like
maternal mortality and life expectancy? After all, the U.S.
is not the only country where class matters. Here, Schroeder points to an
uncomfortable fact: “nations
differgreatly in their degree of social inequality.” [my
emphasis]And in
the U.S., in
recent decades, the gap between the haves and the have nots has widened, to a
point that we have become a divided nation.

Wages at the top of the ladder
have spiraled while wages in the lower rungs have flattened or even fallen. Meanwhile
tax policies have favor the rich, particularly
in the 1980s, under President Reagan, and in recent years, under the current
administration. Even in the late 1990s, during President Clinton’s last term,
the wealth of a prosperous economy did not trickle down: between 1997 and 2001
the top 10 percent of U.S. earners received 49 percent of the growth in real
wages and salaries; and the top 1 percent reaped 24 percent of the total while
the bottom half of workers received less than 13 percent.

Granted, inequality was growing
in most of the rest of the world over the same span, “but the United
States led among the richer nations; and unlike
most others that offset market inequality though government intervention, the United States has not done so,” observes William K. Tabb,
author of Economic Governance in the Age of Globalization.

This may say something about our
priorities as a nation. “One reason the United States does poorly in international healthcomparisons may be that we value entrepreneurialism over egalitarianism,”
Schroeder notes. “Our willingness to tolerate large gaps in income, total
wealth,educational quality, and housing has unintended health
consequences.Until we are willing to confront this reality, our
performanceon measures of health will suffer.”

Yet, he suggests, we could do
better, first by recognizing how social policies involving education, taxation,
transportation and housing have important health consequences and by analyzing
the impact of these policies on health.

Moreover, when it comes to health policy, he
observes, we need to focus on the social and environmental factors which affect
the health of the less fortunate people in our society.. Instead, in a nation
where health care has become big business, we pour the bulk of our health care
dollars into “the development of new medical technologies and support forbasic
biomedical research. We already lead the world in theper capita use
of most diagnostic and therapeutic medical technologies,” Schroeders notes, “and
we have recently doubled the budget for the National Institutesof
Health. But these popular achievements are unlikely to improveour
relative performance on health [when compared to other countries.] “

Perhaps our health care policy reflects our
values. “It is arguable that
thestatus quo is an accurate expression of the national politicalwill,”says Schroeder“a relentless search for better health
among themiddle and upper classes. [my emphasis]. This pursuit is also evident in howwe
consistently outspend all other countries in the use of alternativemedicines
and cosmetic surgeries and in how frequently health"cures"
and "scares" are featured in the
popular media. Theresult is that only when the middle class
feels threatened byexternal menaces (e.g., secondhand tobacco
smoke, bioterrorism,and airplane exposure to multidrug-resistant
tuberculosis) willit embrace public health measures. In contrast,
our investmentin improving population health — whether judged on
thebasis of support for research, insurance coverage, or
government-sponsoredpublic health activities — is anemic.”

And yet, and yet . . . Schroeder sees reason for “cautious
optimism.” Although we trail behind
other countries, we are healthier than we once were. We have reduced smoking
ratse, homicide rates and motor-vehicle accidents. Vaccines and cardiovascular
drugs have improved medical care. But progress in other areas will require
“politicalaction,” Schroeder declares, “starting with relentless
measurement of and focus onactual health status and the actions
that could improve it.Inaction means acceptance of America’s
poor health status.”

If we got serious about
improving public health we could improve productivity, boost the economy, rein
in health care spending and “most important, improve people’s lives” Schroeder
argues. Here, he calls on physicians and other healthcare professionals to
become “champions” for public health. In the end though, it is not only health
professionals, Schroeder suggests, but all Americans who should see improving
the health of the nation as a matter of patriotism. “Americans take greatpride
in asserting that we are number one in terms of wealth,number of
Nobel Prizes, and military strength. Why
don’t wetry to become number one in health? “